Study protocol for The GOAL Trial: comprehensive geriatric assessment for frail older people with chronic kidney disease to increase attainment of patient-identified goals-a cluster randomised controlled trial

Comprehensive geriatric assessment for frail older people with chronic kidney disease to increase attainment of patient-identified goals: Statistical analysis plan for a cluster-randomised controlled trial

BACKGROUND

Frailty is highly prevalent in older people with chronic kidney disease (CKD) and associated with more complex healthcare needs. As part of person-centred care, healthcare planning should be tailored to the individual's needs and their desired outcomes. Comprehensive Geriatric Assessment (CGA) is an intervention which can help facilitate this by identifying a person's medical, functional, and psychosocial problems, and then tailoring a coordinated, targeted management plan. The GOAL trial was designed to establish whether, compared to usual care, a CGA would better enable a person to achieve their own set goals, as measured by Goal Attainment Scaling (GAS). This paper presents the statistical analysis plan (SAP) for the GOAL trial.

METHODS

The GOAL trial is a pragmatic, multi-centre, superiority, open-label, cluster-randomised controlled trial designed to enrol 500 frail, older people (Frailty Index >0.25, aged ≥65 or ≥ 55 years if First Nations people) with moderate to severe CKD (estimated glomerular filtration rate < 59 mL/min/1.73m2) across 16 hospital sites in Australia, and 12 months of follow-up. The primary question (effect of CGA on GAS at 3 months) will be modelled using mixed-effects linear regression. The SAP details the analysis and reporting methods.

CONCLUSIONS

The SAP described here resulted from an iterative, collaborative effort among statisticians and clinician leads of the GOAL trial. Specification of statistical methods prior to trial completion will contribute to unbiased analyses of the collected data.

TRIAL REGISTRATION

ClinicalTrials.govNCT04538157.

Subjective and objectives measures of frailty among adults with advanced chronic kidney disease: a cross-sectional analysis of clinician misclassification

BACKGROUND

Frailty is a recognisable clinical measure of impaired physiological reserve and vulnerability to adverse outcomes that is validated among patients with kidney disease. Practice patterns reveal inconsistent use of objective frailty measures by nephrologists, with clinicians prioritising subjective clinical impressions, possibly risking misclassification and discrimination.

AIMS

The aim of this study was to examine correlations between subjective and objective measures of frailty in a cohort of patients attending routine nephrologist review.

METHODS

Eighty-nine participants attending scheduled review with their primary treating nephrologist (n = 6) were included in cross-sectional analysis. Measured frailty based on Fried phenotype and subjective clinician impression were assessed for congruence using Pearson's correlation analysis and ĸ statistic. Ordinal logistic regression examined patient demographics associated with perceived frailty. Misclassification was explored using descriptive statistics and contingency table analysis.

RESULTS

Frailty and prefrailty were prevalent by both objective and subjective means of assessment with minimal correlation between clinician impression and measured Fried phenotype (r = 0.50, P = 0.00, ĸ = 0.25, P =& 0.00). Subjective clinician impression misclassified half of participants, influenced by surrogate frailty measures including female sex, comorbidity and reliance on a walking aid. Clinicians were equally likely to over-classify prefrailty as to under-recognise established frailty, with no evidence of systemic misclassification bias. Subjective clinican impression of frailty had a positive predictive value of 19.1% and a negative predictive value of 56.2%.

CONCLUSIONS

Nephrologists' reliance on subjective clinical impressions that overlook or misclassify prefrailty offers incomplete prognostic assessment and potentially misses opportunities for early intervention.

Geriatric Assessment in Older Patients with Advanced Kidney Disease: A Key to Personalized Care and Shared Decision-Making-A Narrative Review

As the global population ages, so too does the prevalence of older people with chronic kidney disease (CKD). Helping people age well with CKD and supporting older people with end-stage kidney disease (ESKD) to make personalized decisions regarding kidney replacement therapy (KRT) or conservative care (CC) are an essential component of care. However, these factors are relatively underreported in both the fields of nephrology and geriatric medicine, and prospective, randomized evidence is lacking. This narrative review article, authored by both nephrologists and geriatricians, discusses specific geriatric issues that arise in older people with CKD and why they matter. The available evidence for KRT or CC in older people with frailty is outlined. The importance of performing a comprehensive geriatric assessment, or a modified nephrogeriatric assessment, to ensure a systematic evaluation of the person's medical problems and life needs, goals, and values is described. We consider different models of nephrogeriatric care and how they may be implemented. Kidney supportive care-addressing an individual's symptoms and overall well-being alongside the more traditional nephrological principles of preventing disease progression and optimizing risk-is highlighted throughout the article. We outline ways of identifying the later stages of a person's disease journey, when transition to palliative care is indicated, and elaborate methods of preparing patients for this through multidisciplinary advance care planning. Finally, we discuss practice and systems for nephrogeriatric care in five different European countries and consider future directions, challenges, and highlights in this rapidly evolving, increasingly relevant field.

Kidney replacement therapies in the older person: challenges to decide the best option

A multitude of challenges exist when supporting older adults in deciding on the optimal kidney replacement therapy (KRT), including frailty, comorbidity, cognitive impairment, dialysis modality, as well as local availability of services. The combination of these factors can determine treatment outcomes and quality of life (QoL), and as such the care of older people should be tailored to take these into account. Frailty in older people with chronic kidney disease (CKD) leads to higher rates of hospitalization, increased mortality, and a diminished QoL, while cognitive impairment, present in up to 50% of people with CKD, exacerbates these challenges and affects decision making. Dialysis, particularly haemodialysis, can accelerate physical and cognitive decline in frail older adults. Conversely, peritoneal dialysis (PD) presents a home-based alternative that may better support QoL, particularly for people wanting to prioritize treatment flexibility and independence. Assisted PD programmes have emerged as a valuable option for older people who cannot manage home-based care independently, improving access to KRT. Ultimately shared decision making should be employed when discussing KRT, incorporating patient goals, prognostic awareness, and QoL measures. There is also the emerging role of the geriatrician and the need for an integrated Comprehensive Geriatric Assessment. These elements support older adults to make informed choices that align with the individuals' values and health needs. In designing future health services to meet the needs of increasing numbers of older people, there needs to be increased access to assisted PD as well as multidisciplinary working to ensure patient-focused care surrounding KRT in older adults.

Baseline Characteristics of Frailty and Disease Stage in Older People Living With CKD

Introduction

The GOAL trial, a cluster randomized controlled trial, investigated the effect of comprehensive geriatric assessment (CGA) on frail older people with chronic kidney disease (CKD). This paper describes the following: (i) participant baseline characteristics, and (ii) their relationship with CKD stage and frailty severity.

Methods

Sixteen kidney outpatient clinics (clusters) were randomly allocated 1:1 to CGA or usual care. Enrolled frail older people with CKD (Frailty Index [FI] > 0.25; aged ≥65 years or ≥55 if First Nations people) received the intervention allocated to their cluster. CKD was defined as moderate (stages 3 or 4) or severe (stage 5 or 5D), and frailty categorized as moderate (>0.25-<0.36), severe (0.36-<0.45) or very severe (≥0.45). Participant characteristics were analyzed using descriptive statistics. Statistical methods appropriate for type of outcome were used to describe the association of frailty and CKD categories with participant characteristics.

Results

Over a 27-month period, 240 people were recruited (55.7% male, 82.9% White/European). Mean age was 76.9 (SD: 6.6) years and median FI was 0.39 (interquartile range [IQR]: 0.32-0.47). The median EQ-5D-5L quality-of-life index score was worse in those with very severe frailty (0.57, IQR: 0.28-0.83) compared to severe frailty (0.85, IQR: 0.67-0.92) and moderate frailty (0.90, IQR: 0.82-0.93) (overall P < 0.001). Median EQ-5D-5L was also worse in those with severe CKD (0.79, IQR: 0.40-0.89), compared to moderate CKD (median 0.87, IQR: 0.73-0.92; P = 0.001).

Conclusion

This cohort demonstrated poorer quality-of-life scores in those with more severe frailty and more advanced CKD.

How do geriatricians practise comprehensive geriatric assessment in the outpatient setting: an analysis of geriatricians' letters and a comparison to the Medicare benefits schedule requirement

BACKGROUND

Little is known about what components geriatricians routinely incorporate into outpatient comprehensive geriatric assessments (CGAs).

AIMS

This study explored what components of CGAs are routinely incorporated into geriatricians' letters and assessed their consistency with the Medicare Benefits Schedule (MBS) and a recently published survey of geriatricians.

METHODS

We completed a manual content analysis, supplemented by qualitative thematic analysis, of 34 letters from five geriatricians, collected as part of the GOAL Trial.

RESULTS

While more than 80% of letters included each of the key clinical domains described in the Medicare Benefits Schedule and survey of geriatricians, only 62% included advanced care planning and 47% mentioned immunisations. Forty-seven percent of letters included goal setting. Few letters showed evidence of multidisciplinary working. Issues identified by the geriatrician centred around the themes of advance care planning, symptom identification and management, medical comorbidities, strategies to support quality of life and interventions to manage frailty. Patient concerns identified in the letters were cognition and mood, declining function, future planning and symptom management.

CONCLUSIONS

Analysis of geriatricians' letters provides important and novel insights into usual CGA practice. The letters provide evidence of multidimensional assessments of physical, functional, social and psychological health, and most include use of standardised tools. However, less than 50% include evidence of goal setting or multidisciplinary working. The results allow consideration of how CGAs might be carried out in the outpatient setting, so that interventions focused on improving the quality and efficacy of this intervention can be implemented.

How to make a shared decision with older persons for end-stage kidney disease treatment: the added value of geronto-nephrology

Improving care for older people with end-stage kidney disease (ESKD) requires the adaptation of standards to meet their needs. This may be complex due to their heterogeneity in terms of multimorbidity, frailty, cognitive decline and healthcare priorities. As benefits and risks are uncertain for these persons, choosing an appropriate treatment is a daily challenge for nephrologists. In this narrative review, we aimed to describe the issues associated with healthcare for older people, with a specific focus on decision-making processes; apply these concepts to the context of ESKD; identify components and modalities of shared decision-making and suggest means to improve care pathways. To this end, we propose a geronto-nephrology dynamic, described here as the necessary collaboration between these specialties. Underscoring gaps in the current evidence in this field led us to suggest priority research orientations.

Protocol for the process evaluation of the GOAL trial: investigating how comprehensive geriatric assessment (CGA) improves patient-centred goal attainment in older adults with chronic kidney disease in the outpatient setting

INTRODUCTION

The GOAL Cluster Randomised Controlled Trial (NCT04538157) is now underway, investigating the impact of comprehensive geriatric assessment (CGA) for frail older people with chronic kidney disease (CKD). The primary outcome is the attainment of patient-identified goals at 3 months, assessed using the goal attainment scaling process. The protocol requires a dedicated process evaluation that will occur alongside the main trial, to investigate issues of implementation, mechanisms of impact and contextual factors that may influence intervention success. This process evaluation will offer novel insights into how and why CGA might be beneficial for frail older adults with CKD and provide guidance when considering how to implement this complex intervention into clinical practice.

METHODS AND ANALYSIS

This process evaluation protocol follows guidance from the Medical Research Council and published guidance specific for the evaluation of cluster-randomised trials. A mixed methodological approach will be taken using data collected as part of the main trial and data collected specifically for the process evaluation. Recruitment and process data will include site feasibility surveys, screening logs and site issues registers from all sites, and minutes of meetings with intervention and control sites. Redacted CGA letters will be analysed both descriptively and qualitatively. Approximately 60 semistructured interviews will be analysed with a qualitative approach using a reflexive thematic analysis, with both inductive and deductive approaches underpinned by an interpretivist perspective. Qualitative analyses will be reported according to the Consolidated criteria for Reporting Qualitative research guidelines. The Standards for Quality Improvement Reporting Excellence guidelines will also be followed.

ETHICS AND DISSEMINATION

Ethics approval has been granted through Metro South Human Research Ethics Committee (HREC/2020/QMS/62883). Dissemination will occur through peer-reviewed journals and feedback to trial participants will be facilitated through the central coordinating centre.

TRIAL REGISTRATION NUMBER

NCT04538157.

Geriatric Assessment in CKD Care: An Implementation Study

Rationale & Objective

Older people with progressive chronic kidney disease (CKD) have complex health care needs. Geriatric evaluation preceding decision making for kidney replacement is recommended in guidelines, but implementation is lacking in routine care. We aimed to evaluate implementation of geriatric assessment in CKD care.

Study Design

Mixed methods implementation study.

Setting & Participants

Dutch nephrology centers were approached for implementation of geriatric assessment in patients aged ≥70 years and with an estimated glomerular filtration rate of ≤20 mL/min/1.73 m2.

Quality Improvement Activities/Exposure

We implemented a consensus-based nephrology-tailored geriatric assessment: a patient questionnaire and professionally administered test set comprising 16 instruments covering functional, cognitive, psychosocial, and somatic domains and patient-reported outcome measures.

Outcomes

We aimed for implementation in 10 centers and 200 patients. Implementation was evaluated by (i) perceived enablers and barriers of implementation, including integration in work routines (Normalization Measure Development Tool) and (ii) relevance of the instruments to routine care for the target population.

Analytical Approach

Variations in implementation practices were described based on field notes. The postimplementation survey among health care professionals was analyzed descriptively, using an explanatory qualitative approach for open-ended questions.

Results

Geriatric assessment was implemented in 10 centers among 191 patients. Survey respondents (n = 71, 88% response rate) identified determinants that facilitated implementation, ie, multidisciplinary collaboration (with geriatricians) -meetings and reports and execution of assessments by nurses. Barriers to implementation were patient illiteracy or language barrier, time constraints, and patient burden. Professionals considered geriatric assessment sufficiently integrated into work routines (mean, 6.7/10 ± 2.0 [SD]) but also subject to improvement. Likewise, the relevance of geriatric assessment for routine care was scored as 7.8/10 ± 1.2. The Clinical Frailty Score and Montreal Cognitive Assessment were perceived as the most relevant instruments.

Limitations

Selection bias of interventions' early adopters may limit generalizability.

Conclusions

Geriatric assessment could successfully be integrated in CKD care and was perceived relevant to health care professionals.

Training healthcare professionals to administer Goal Attainment Scaling as an outcome measure

BACKGROUND

Goals generated by Goal Attainment Scaling (GAS) can be used as an outcome measure to promote person-centred research and care. There are no training packages which support its use outside of the rehabilitation discipline. This paper describes the development and evaluation of a training package to support the implementation of GAS as an outcome measure in healthcare research. The training package consisted of classroom teaching, a training manual for self-directed learning, one-on-one simulation and hot reviews. It was developed for the GOAL Trial, a randomised controlled trial assessing a Comprehensive Geriatric Assessment's effectiveness in enabling frail older people living with chronic kidney disease to attain their goals. Training participants were invited to complete pre- and post-training online evaluation surveys.

RESULTS

Forty-two healthcare professionals attended an initial online classroom teaching, with 27 proceeding to administer GAS to GOAL Trial patients. Response rates for the online pre- and post-training surveys were 95% and 72%, respectively. Prior to training, only 15% of participants reported being able to appropriately scale and troubleshoot GAS goals. Post-training this was 92%. There was 100% participant satisfaction for the training manual, one-on-one simulation, and hot reviews.

CONCLUSIONS

This training package helps ensure healthcare professionals administering GAS have adequate knowledge and skills. It has the potential for adoption as a guide to support the implementation of GAS by other researchers seeking to embrace persont-centred principles in their work.